Volume 20 March 2022 Peer Reviewed Journal

UNIVERSITY OF BOHOL,
Print ISSN 2362-9142 • Elecronic ISSN 2362-9215 GRADUATE SCHOOL
DOI: https://doi.org/10.15631/aubgsps.v20i1.183 ACADEME AND PROFESSIONAL
STUDIES JOURNAL

Stress Factors Among Nursing Students

LIESEL A. ROBERSON
[email protected]
https://orcid.org/0009-0007-6194-0230

LEE ANN B. AMPONG

[email protected]
https://orcid.org/0009-0008-2708-7931

JOSEPH J. CAMPANO JR.

[email protected]
https://orcid.org/0009-0007-8309-2236

ALJOHN J. INDUS
[email protected]
https://orcid.org/0009-0007-5917-6472

MARY ANA JEANE OGUIS

[email protected]
https://orcid.org/0009-0006-1916-3215

REY ANGELO G. SAGARAL

[email protected]
https://orcid.org/0009-0001-6285-4736

JASMIN C. LABURADA
[email protected]
https://orcid.org/0009-0007-1868-1974

This work is licensed under a Creative Commons

Attribution-NonCommercial 4.0 International License.

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AZUCENA F. SALAUM
[email protected]
https://orcid.org/0009-0007-5268-9873

BERYL ELIZABETH B. LUPOT

[email protected]
https://orcid.org/0009-0007-0832-5503

ABSTRACT

Stress is a health epidemic of the 21st Century. It can affect anyone

at anytime, altering or impairing their general health (WHO). The study
utilized the quantitative- descriptive correlational research design to
determine the stress factors among the two hundred randomly selected
nursing students of the University of Bohol, aided by a self-made
questionnaire adopted from the Student Nurse Stress Index (SNSI) by
Jones and Johnston 1999. The tool underwent Cronbach’s Alpha test with
a reliable result. The instrument was distributed online. Findings revealed
that most respondents are young adults from 20-21 years old, female, and
single. The respondents are moderately stressed with academic concerns
and internet connectivity, followed by interpersonal and interpersonal
problems. When the data were subjected statistically using SPSS with
Spearman’s rho test and chi-square, it was found that the year level has a
significant relationship to stress levels.

Keywords: Stress, academic concern, internet connectivity,

intrapersonal, interpersonal, quantative-descriptive-correlationsal,
Spearman rho test, Chi-square, Bohol, Philippines

INTRODUCTION

For nursing students, stress is a widespread problem. Nursing

students have a higher stress level than the overall student population in
other disciplines (Şentürk & Dogam, 2018). During their nursing education,
the students either directly or indirectly become tense from various stress
factors that may hinder their learning and performance (Labrague, 2013;
Sakellari, Psychogiou, Georgiou, Papanidi, Vlachou, & Sapountzi-Krepia,
2018).

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Since the pandemic, the education system has shifted from face-to-
face to online classes. Digital education has been adopted as the source
of student education (Gautam, 2020). Students from different year levels
experienced a lot of anxiety as they tried to adapt to this new educational
system. They have experienced difficulty adapting to new technology
and manipulating other digital learning platforms. Heavy assignments,
adjusting to the use of new technology, problems with internet connectivity,
and concerns about maintaining an excellent interpersonal relationship
with groupmates when working as a team in a group. It has given rise
to depression and anxiety disorders among undergraduate university
students who experience stressful workloads, problems with internet
connections, and challenges adapting to digital platforms and devices
(Fawaz & Samaha, 2020).
Stress among nursing students focuses on their academic performance
and environmental and clinical contexts (Parveen & Inayat 2017). In
the educational context, students will become stressed when getting
low scores, lack career advancement, and inability to balance study and
leisure time. In the Clinical context, 39.3% of the students strongly agreed
that maintaining a balance between clinical work and studying increases
stress, and 44% on the behavior of the physician and nurses, and staff
who criticized students in front of the patient induces stress as well. In
the Environmental context, 64.7% of the students agreed that the lack of
recreational facilities during the semester is a source or factor of stressors,
and 97.3% of stress due to security risks in the job area causes stress
(Parveen & Inayat, 2017).
According to the transactional model theory of stress and coping
(Lazarus & Folkman, 1984), stress is the effect of an interplay between
the individual and the environment. The theory defines stressors as the
subjective assessment of a threatening or harmful condition. Lazarus and
Folkman believed that stress is a crucial factor causing a bad equilibrium
between the demands of students’ lives. Their mental and physical health
are also affected, causing anxiety that may result from internal perception
or external environmental stimuli. Lazarus and Folkman suggested that
daily hassles, which often appear unimportant in life, can be often taken
for granted, which in itself can be stressful. Daily hassles among students
are experiences that can attribute to anger, exasperation or irritation,
distress or anxiety, and ultimately feelings exaggerated by responsibilities,
which can form through an argument or disagreement, financial issues,
and family worries or misunderstanding (Lazarus, 2013).
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Different Students experience different kinds of stressors. Everyday

stressors identified are the pressures to succeed in academics and life
uncertainties (Shanmugam, 2017). The poor academic performance of
the students is the cause of the ramifications of stress problems (Kernan
& Wheat, 2008). The psychosocial phenomenon of stress problems
causes pessimistic outcomes in nursing students’ academic achievement,
personal health, and overall well-being (Crone & Dahl, 2012; Yıldırım,
Karaca, Cangur, Acıkgoz, & Akkus, 2017; Shdaifat, 2018).
Students experienced challenges that caused negative perceptions
and low self-esteem affecting their academic performance and general
health (Alghamdi, 2019). During clinical practice, nursing students often
experience a high level of anxiety that can cause psychological and
emotional problems affecting poor performance in providing care to the
patient. Inadequate knowledge and skills, on the other hand, can also
trigger stress (Findik, Ozbas, Cavdar, Topcu & Onler, 2015). This has been
seen among students from the lower level who often experience stress
as they have difficulty understanding different medical terminologies as
they read their assigned patients’ health histories, medical diagnoses, and
treatment (Aedh, Elfaki, & Mohamed, 2015). Nursing students experience
multiple stressors as they apply theoretical learning and develop critical
thinking skills professionally. This overwhelming negative stressor can
lead to absenteeism and dissatisfaction (Kulland, 2014) among students.
Experiencing elevated levels of stress causes harm. When students
cannot cope with stress adequately, it will affect their academic
performance and interpersonal and intrapersonal relationships. Student
nurses develop an interpersonal change in their social activities as they
will have problems communicating their concerns with their close friends
leading to conflict (Shanmugam, 2017). A heightened stress response will
deteriorate nursing students’ physical, psychological, and mental health.
Stress causes nursing students to feel more detached and apathetic,
contributing to their failure to manage and resolve situations (Dardas,
2015). Increased stress and low coping mechanisms may also lead to
poor academic performance and burnout among nursing students (Shultz,
2011).
A study by Tim (2019) shows that social, environmental, academic,
personal, and emotional factors affect nursing students. The fear of
getting a failing grade, having low self-esteem, impaired sleep patterns,
low satisfaction towards performance or work or discomfort, nervousness,

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tiredness, and decreased financial aid cause stress to the students (Tim,
2019). Aside from that, exposure in clinical practice is another stressor
perceived by nursing students, especially when exposed to the Intensive
Care Unit, Emergency Room, Surgical Ward, and Medical units (Aedh et
al. 2015). The tons of written requirements given to the students before
their clinical exposure and taking care of different kinds of patients also
cause stress.
During the pandemic, the University of Bohol College of Nursing
has implemented online learning, both in theory and in their Related
Learning Experience. This context prompted the researchers to conduct
this study to determine the stress level among nursing students at the
University of Bohol. The study looks into the profile of the respondents
and determines the respondent’s stress levels in terms of academic
concerns, intrapersonal and interpersonal relationships, and internet
connectivity problems. It examined the significant relationship between the
respondents’ demographic profile and stress levels. The result of the study
served as the basis for formulating an Information Educational Campaign
to help students reduce their perceived stress levels.

RESEARCH METHODOLOGY

This study used a descriptive-correlational quantitative research

design employing random sampling. A questionnaire was distributed
online to the two-hundred randomly selected Level 1-4 nursing students
who consented to participate in the study. The study includes nursing
students of the University of Bohol, 18 years old and above, and officially
enrolled for the second semester of 2020-2021. Excluded from the study
are irregular nursing students. A self-made questionnaire anchored on the
ideas from the SNSI tool by Jones & Johnston (1999) was used in the
study. The tool was pilot tested thrice to ten nursing students. Revisions
were made to vague items until a reliable result was obtained, as shown
below. The student nurses who already participated in the pilot testing
were not included in the data gathering.

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Cronbach Alpha Result

Reliability
Variable Description
Result
Stress from Academic Concern .877
Stress from intrapersonal Concern .728 The tool is reliable. The accepted
Stress from interpersonal concern .782 result is at least .70
Internet Concern .793

The study underwent an ethics review from the University of Bohol

Ethics Review Board. Once clearance from UB-ERB, permission was
secured from the University of Bohol Vice President for Academics, and
the Dean of the College of Nursing, to distribute the questionnaires to the
respondent’s F.B. messenger account. The gathered data was used to
code and strictly observe the confidentiality and privacy of the respondents.
The data information was indeed secured and stored in the google drive
account of the researchers. Only the researchers were permitted to access
the data gathered, and these gathered data were only used for research
purposes. The collected data underwent a normality test to determine the
appropriate statistical test. Results revealed that the distributions of the
data were skewed. Hence, nonparametric tests were employed in testing
the research hypothesis using SPSS.

RESULTS AND DISCUSSION

Demographic Profile of the Respondents. It has been noted that

there are more female respondents than males. The nursing profession is
a caring profession. The social construction of being a nurse has typically
meant a loving, hard-working woman. Male students perceive their image
and status negatively because they often question their muscularity
and sexuality (Ozdemir, Akansel, & Tunk, 2008). Moreover, the female-
dominated nature of nursing, prevalent stereotypes and gender bias
inherent in nursing education seem to make this an uncomfortable place
for male
And those with less gendered typed views. Males were likelier to leave
the nursing course than females (McLaughlin, Muldoon & Moutray, 2009).
Respondent’s Level of Stress. As to the level of stress of the
respondents in terms of academic concern, findings revealed that that

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respondents are “extremely stressed” about having a failing course grade,

followed by the “fear of failing passing scores in examinations.” Taking
examinations, insufficient time to meet commitments, too much academic
work, and fear of oral presentations are common concerns among higher
education students. If not appropriately managed, it will result in dropouts
or low academic performance (Alsulami, Al Omar, Binnwejim, Alhamdan,
Aldrees, Al-Bawardi, & Alhabeeb, (2018). Students fear failing course
grades because of the unfinished quizzes due to the length of questions
and the short timeframe given. Financial issues and personal health
concerns are identified factors that cause the student to be unable to take
the exam or quiz, resulting in a failing mark (Owen, 2015).
In terms of intrapersonal problems, the respondents have “Fear that
one of their parents will get a serious illness,”; followed by “Feeling of
being unhealthy due to lack of sleep” and “Failure to meet the expectations
of parents regarding performance in school” which the respondents
interpret as “moderately stressed.” “Inadequate finances to support tuition
fees” causes “mild stressed” to the respondents. The result conforms
to the nature of children to be worried about their parent’s health and
other family members. The COVID-19 pandemic has caused significant
disruption in education worldwide (Kim, Quiban, Sloan, and Montejano
(2021). Although most colleges have shifted to online learning, some
nursing schools continue to have clinical practicums requiring students to
work in close contact with patients. The concern of viral transmission and
the unpredictable progression of the COVID-19 pandemic contributes to
nursing students’ increased unreliability of academic lead. It also negatively
affects thinking Bublitz, Guido, Kirchhof, Neves, Lopes, and (2021). Due
to an overload of assignments and activities, nursing students experience
sleep deprivation that can affect their academic performance, alter their
mental health, and cause anxiety due to feeling sick or unhealthy.
Regarding stress from an interpersonal relationship, the “Lack of
teamwork and cooperation from groupmates during a group activity” causes
“moderate stress.” In contrast, “Misunderstanding with my roommates,
close friends, and siblings” caused “Mild stressed” to the respondents.
Interpersonal relationships are another factor during nursing education.
Changes in social activities, fights with close ones, lack of cooperation
from friends, lack of immediate and intimate friends, and conflict with
roommates stress nursing students (Shanmugam, 2017). The pandemic
affected the lives of young adult students as they try to continually learn

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academically with the new educational platforms where they experienced

limited to no social life, which causes them to experience stress and
tension (Aslan, Silvia, Nugroho, Ramli, & Rusiadi, 2020).
Regarding stress from access to internet connectivity problems,
Respondents are moderately stressed when they have “unfinished
assignments due to sudden disconnection of the internet” and when there
is “Sudden disconnection during group interaction.” The students struggle
to stabilize the home internet for online classes because of the pandemic.
The education system shifted from face-to-face learning to an online class
method. It would need an internet connection to use electronic devices
for the assignments and requirements to be submitted and other online
class activities. Many students are adjusting to using internet connections,
especially students living in upland or isolated areas with poor or no
internet connection which causes anxiety to nursing students.

Table 1. Summary of the Level of Stress of the Respondents (N=200)

Weighted
Category Descriptor Interpretation Rank
Mean
Academic 3.076 MS Moderately stressed 1.5
Internet
3.076 MS Moderately stressed 1.5
Connectivity
Intrapersonal 2.857 MS Moderately stressed 3
Interpersonal 2.3850 SS Mildly stressed 4
Overall
2.8485 MS Moderately stressed
composite mean

Legend:
Scaling Descriptor Interpretation
1.00 – 1.74 No Stress No stress
1.75 – 2.49 Slightly Stress Mildly stressed
2.50 – 3.24 Moderately Stress Moderately stressed
3.25 – 4.00 Highly Stress Extremely stressed

Data revealed that respondents have moderate stress, especially

regarding the academic concern and internet connectivity. Interpersonal
concerns also cause stress but to a mild degree compared to the three
other identified categories of stress. Some students often aim to achieve
high marks and are concerned about receiving poor grades are just some

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of the top concerns of students academically (Pascoe, Hetrick, & Parker,

2019). The pandemic causes the transition, especially in the educational
system worldwide, which primarily affects third-world countries, including
the Philippines. The new educational system needs technological
involvement and digital devices for online classes. Problems with poor
internet connection and unfamiliar use of technological devices also
cause academic pressure among students (Kansas, 2020). Slow Internet
connections or limited access from homes in rural areas can make students
fall behind academically (Bauer, Brooks & Hampton, 2020). There are
many ways that a lack of internet access can affect a student’s academic
performance. One of the biggest problems students face without internet
access at home is their inability to complete homework or activities
(Lynch, 2017). The effects of stress on nursing students have an impact
on academic performance. This could trigger several psychiatric disorders
as depression or anxiety, as well as other associated problems, such as
sleep disorders, alcohol, and psychoactive drug consumption, which may
affect their patient care (Pulido-Criollo, Cueto-Escobedo, & Guillén-Ruiz,
2018; Parveen & Inayat, 2017).

Table 2. Significant Relationship Between the Respondents’ Profile and

Their Level of Stress (N=200)
Statistical Statistical
Variables P-value Decision Interpretation
Treatment Value
Age and Failed to There is no significant
Spearman’s
Level of -0.137 0.053 reject the null relationship between
Rank Test
Stress hypothesis the variables
Sex/Gender Failed to There is no significant
Spearman’s
and Level of 4.129 .248 reject the null relationship between
Rank Test
Stress hypothesis the variables
Civil status Failed to There is no significant
Spearman’s
and level of 5.838 .699 reject the null relationship between
Rank Test
stress hypothesis the variables
Year Level There is a significant
Chi-square Reject null
and Level of 21.490 0.009 relationship between
test hypothesis
Stress the variables

The gathered data were subjected statistically using SPSS. The age,
Sex, and Civil Status of the respondents and their level of stress were
subjected to Spearman’s Rank Test with a P-value that is higher than the

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0.05 level of significance. This indicates that there is no significant degree

of relationship between age, Sex, and civil status to the levels of stress
perceived by the respondents. On the other hand, when data on the year
level and the stress level were subjected to the chi-square test, it resulted
in a p-value of 0.009 which is lower than the significance level of 0.05, thus
rejecting the hypothesis. This further means that the year level influences
the student’s stress level. Nursing students in the higher level are already
being rotated to clinical areas handling more comprehensive cases than
lower-year level nursing students, which causes the senior students to
perceive higher stress levels than novice students.
Clinical training becomes more stressful than academic training,
especially since clinical training requires adequate knowledge and skills.
Students exposed to the clinical area may also fear making mistakes,
handling emergencies, irregular clinical practice, and visiting specialized
units (Onieva-Zafra, Fernández-Muñoz, Fernández-Martínez, García-
Sánchez, Abreu-Sánchez & Parra-Fernández, 2020). Stress levels increase
according to the training or the academic year or decrease as the student
becomes more trained (Onieva-Zafra, Fernández-Muñoz, Fernández-
Martínez, García-Sánchez, Abreu-Sánchez & Parra-Fernández, 2020).
The closer the students are to the professional phase, the greater the
adaptation effort. The activities developed at each year level offer different
situations that can be perceived as stressful, to a greater or lesser degree,
depending on the student’s cognitive and emotional resources to cope
(Mussi, Pires, Silva, Macedo, & Santos, 2020).

CONCLUSION

Implementing the new educational platform during the pandemic

causes moderate stress to the University of Bohol College of Nursing
students, especially in the academic aspect and internet connectivity.
It also causes moderate stress to their intrapersonal relationship and
mild stress to their interpersonal relationship. Moreover, among the
respondents, a significant association has been found between year level
and the level of stress. Lazarus’s transactional model theory of stress
and coping emphasizes the individual’s and his environment’s interplay.
The demands of the student’s academic activities cause the students to
experience stress, especially when a solid internet connection is highly
needed to comply with the task.

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RECOMMENDATION

1. In coordination with the guidance office, the nursing department

continually conducts programs and training for students to help
them cope with stress.
2. Lobby the Local government for the findings of this study to be
used as a basis for allocating government funds as the budget for
enhancing internet connectivity, especially in rural areas.
3. For the local communities to provide free and easy internet
access to students in their localities, it would be beneficial if an
internet connection is not accessible at the student’s homes. This
would also substantially help students enrolled in online, blended
learning classes who cannot afford a home internet connection. A
designated community access area allows students to participate
in online courses when no other options are available. A national
government’s general function and purpose are to provide the
necessary safeguards and tools i’s society requires. Government
assistance to the student population allows them to learn online
techniques in this modern world, which is a fundamental tool for the
progress of its society.
4. Trained nurses are in shortage and demand in every corner of the
planet. The pandemic has created this awareness of how valuable
highly trained nurses are to survival in these catastrophic times.
It makes sense that we need not only to bolster and significantly
increase our trained medical personnel, but they need to be trained
and have experience using the advanced medical technology
available in this relatively new millennium. Encouraging new
nursing students to prepare to enter the profession is of paramount
importance, so we must take care of them. We can do this by
understanding and relieving as much unnecessary stress as
possible during their educational training to prevent levels of
discouragement that causes them to leave before completion. It’s
not possible to eliminate all stress in learning. A certain amount
of stress and anxiety often pushes us to excel, but it must be
manageable. With attention and awareness of the problem, it can
be controlled and lessened not to overwhelm young students who
desperately need to be trained in the medical profession.

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